Musculoskeletal

injury
BY : RISA HERLIANITA, MSN
The Bodys Scaffolding: The Skeleton
Axial skeleton Appendicular skeleton
Vertebral column Pectoral girdle
Skull Pelvic girdle
Rib cage Upper and lower extremities
Spinal column
 Shoulder and Upper Extremities
The pectoral girdle is composed of:
Two scapulae (shoulder blades)
Two clavicles (collarbone)
Shoulder and Upper Extremities
The upper extremity joins the
shoulder girdle at the glenohumeral
joint.
The forearm is made up of the
radius and ulna.
Shoulder and Upper Extremities
Hand consists of:
Carpals
Metacarpals
Phalanges
Pelvis and Lower Extremities
The pelvic girdle is three bones
fused together:
Ischium
Ilium
Pubis
 Pelvis and Lower Extremities
The lower extremity is the:
Thigh
Leg
Foot
Pelvis and Lower Extremities
Three classes of foot bones:
Tarsals
Metatarsals
Phalanges
Joints
Injury Forces and Motions
Direct force
Occurs when the force of an
impact is too great to be
absorbed by the soft tissue
Indirect force
Occurs when the force applied to
one part of the body is
transmitted to a weaker area
Fractures
Classification
May be classified based on type of
displacement
 Fractures
Classification (contd)
Open fracture: skin is broken.
Closed fracture: skin remains intact.

Courtesy of Rhonda Beck

Fractures
Signs/symptoms
Pain close to site
Deformity
Shortening
Swelling
Guarding
Tenderness
Crepitus
Exposed bone
Chuck Stewart, MD.
Ligament Injuries and Dislocations
Dislocation: Bone is totally displaced from the joint.
Evaluation reveals:
Obvious and significant deformity
Significant decrease in joints ROM
Severe pain
Ligament Injuries and Dislocations
Dislocation (contd)
Subluxation: Partial dislocation
Luxation: Complete dislocation
Diastasis: Ligaments that hold two bones in place are disrupted
Ligament Injuries and Dislocations
Sprains: Ligaments are stretched or torn.
Typical symptoms include:
Pain
Swelling
Discoloration over the injured joint
Muscle and Tendon Injuries
Strains
Achilles tendon rupture
Injuries related to inflammatory responses
Bursitis
Tendinitis
 Injuries That May Signify Fractures
Amputation: Separation of a limb or
other body part from the rest of the
body
May be complete or incomplete

Courtesy of Andrew N. Pollak, MD, FAAOS

Injuries That May Signify Fractures
Laceration: Smooth or jagged cut caused by a sharp object or a blunt force
Depth of the injury can vary.
Deep lacerations may cause nerve injury.
Patient Assessment
Patients may be classified based on injury:
Life- or limb-threatening injury or condition
Life-threatening injuries, simple musculoskeletal trauma
Life- or limb-threatening musculoskeletal trauma
Isolated, nonlife- or nonlimb-threatening injury
Scene Size-Up
Focus on safety and standard precautions.
Consider the mechanism of injury (MOI).
Request additional resources as needed.
Primary Assessment
Focus on mental status, ABCs, and priority.
Priorities should include:
Identifying the injuries
Preventing further harm or damage
Supporting the injured area
Administering pain medication if necessary
Primary Assessment
Form a general impression.
Evaluate level of consciousness.
If there was significant trauma, musculoskeletal injuries may be a lower priority.
Do not waste time on prolonged assessment.
Complete additional assessment during transport.
Primary Assessment
Airway and breathing
Very little else matters if the patients airway and breathing are inadequate.
Evaluate the chief complaint and MOI.
Primary Assessment
Circulation
Hypoperfusion is a primary concern.
Treat the patient for shock immediately.
Assess for pulses proximal to injury, and note any circulatory changes.
Check for external bleeding.
Primary Assessment
Transport decision
Rapid transport should be provided for:
Patients with airway or breathing problems
Patients with significant bleeding
Patients with a significant MOI
Patients with simple MOIs may be stabilized prior to transport.
History Taking
Use the standard SAMPLE format.
Obtain information about the incident.
Condition and position of patient before incident
Details of incident
Position of patient after incident
Secondary Assessment
Obtain a baseline set of vital signs.
Compare one side of the injured extremity with the other.
Perform and exam, noting DCAP-BTLS.
Secondary Assessment
Cover the 6 Ps: Pain
Pain Remember OPQRST mnemonic.
Paralysis Ask the patient to rate pain on a
Paresthesias 1 to 10 scale.
Pulselessness
Pallor
Pressure
Secondary Assessment
Inspection
Check for:
Deformity
Skin changes
Swelling
Muscle spasms
Abnormal limb positioning
Increased or decreased ROM
Color changes
Bleeding
Secondary Assessment
Palpation
Check for point tenderness.
Identify instability, deformity, abnormal joint or bone continuity, and displaced bones.
Feel for crepitus.
Palpate distal pulses.
Palpate pelvis and upper and lower extremities.
Secondary Assessment
Motor function and sensory exam
Check that the patient does not have a life-threatening injury.
Consider the preinjury level of function.
Compare both sides of the body.
Reassessment
The overall goal is to identify the type and extent of the injury and to provide treatment.
Treatment begins in the field.
General Treatment of Fractures and
Sprains
Fractures Sprains
Control external bleeding. Immobilize.
Prevent infection. Chill.
Manage internal bleeding. Elevate.
Immobilize. Splint.
Reduce weight bearing.
Manage pain.
Volume Deficit Due to Musculoskeletal
Injuries
Prevent hypotension and instability.
Apply pressure.
Splint.
Administer IV fluids.
Pain Control
Assess the patients pain level.
Try simple measures to control pain.
Splint
Rest and elevation
Heat or ice

If measures fail, administer an analgesic or antispasmodic agent.

Cold and Heat Application
During the first 48 hours, cold packs can be used to reduce pain and swelling.
Heat therapy should be avoided in the first 48 to 72 hours, but can then be used to:
Increase blood flow.
Decrease stiffness.
Splinting
Decreases pain
Reduces risk of further damage
Controls bleeding
Principles of Splinting
Make sure the injured area can be seen.
Assess and record distal PMS functions.
Cover all wounds with a sterile dressing.
Do not move the patient before splinting.
Fracturesimmobilize bone ends and joints.
Principles of Splinting
Dislocationssplint entire length of bone.
Pad the splint well.
Support the injury and minimize movement.
Splint knees straight, elbows at right angle.
Discontinue traction if patient reports pain.
Principles of Splinting
Splint firmly.
Avoid covering fingers and toes.
Apply cold packs, and elevate the limb.
In the case of life-threatening injuries, splinting should not delay transport.
Pediatric Fractures
Weakness of growth plates makes childrens bones vulnerable to fracture.
Tenderness, swelling, and bruising tend to be at a lower level.
Pelvic fractures are unusual.
Assessment and Management
When assessing, look for signs of abuse.
Adjust your approach as needed.
Stabilize all sprains and fractures.
Transport child with a family member.
Complications of Musculoskeletal Injuries
Likelihood of complication is due to:
Strength of force that caused the injury
Location of the injury
Patients overall health
Complications of Musculoskeletal Injuries
Paramedics can reduce the probability of long-term disability by:
Preventing further injury
Reducing the risk of wound infection
Minimizing pain
Transporting to appropriate facility
Vascular and Neurovascular Injuries
Devascularization: Loss of blood flow to a body part, occurring when blood vessels are damaged
following a musculoskeletal injury
Neurovascular injuries occur when the skeletal system is compromised.
Vascular and Neurovascular Injuries
Assessment and management
Assess and reassess pulses.
Control bleeding.
Maintain adequate intravascular volume.
Compartment Syndrome
Condition that occurs when pressure is too high within fascia
Causes include:
Overly tight bandages, splints, casts, or PASG
Fracture, dislocation, crush injury, vascular injury, soft-tissue injury, bleeding disorder
Fluid leakage or edema
Compartment Syndrome
Assessment
The first sign is searing or burning pain out of proportion to the injury.
Neurologic symptoms include:
Paresthesias
Paralysis of involved muscles
Pulselessness is a late sign.
Compartment Syndrome
Management
Elevate the extremity to heart level.
Apply cold packs.
Open or loosen constrictive clothing or splint.
Administer high-flow oxygen and isotonic crystalloid solution.
Shoulder Girdle
Clavicle fractures: Shoulder injury:
Pain in shoulder Swelling
Swelling Ecchymosis
Unwillingness to raise the arm Pain
Tilting of the head toward
fracture Scapular fracture:
Pain that increases with arm
abduction
Swelling
Shoulder Girdle
Management
Treat shoulder fractures with a sling or swathe.
Treat suspected scapula fractures with full spinal stabilization.
Elbow
Distal humerus
Supracondylar fractures typically
occur as a result of falling onto
an outstretched hand.
Proximal radius and ulna
Radial head fractures occur as a
result of falling onto an
outstretched hand or from a
direct blow.
Elbow
Signs of a distal humerus Signs of a radial head
fracture: fracture:
Pain in the elbow Pain associated with supination
Significant swelling or pronation
Ecchymosis Ecchymosis
Elbow
Treatment of injuries is the same:
Repeatedly assess for compartment syndrome.
Conduct a neurovascular exam before splinting.
If there is a distal pulse, splint.
If there is no distal pulse, consult medical facility.
Transport the patient gently.
Forearm
Fractures may involve radius, ulna, or both.
Typically occur as a result of:
Direct blow (nightstick fracture)
Falling onto outstretched hand (Colles fracture)
Forearm
Signs of a Colles fracture Treatment includes:
include: Splinting
Dorsally angulated deformity of Application of cold packs
the distal forearm Neurovascular exams
Pain
Swelling
Pelvis
Disruptions of the pelvic ring occur
secondary to high-energy trauma.
If pelvic injury exists, suspect
multisystem trauma.
Pelvis
Structures at risk for injury Blood vessels most prone to
with pelvis fracture: damage:
Bladder Veins within pelvis
Urethra
Nerves at greatest risk of
Rectum
injury:
Vagina
Those in lumbar and sacral
Sacral nerve plexus regions
Sciatic nerves
Femoral nerves
Pelvis
Lateral compression pelvic ring
disruptions
Result from side body impact
Lower risk of hemorrhage

Courtesy of Andrew N. Pollak, MD, FAAOS

Pelvis
Open pelvic fractures
Injury to the major vascular structures can cause life-threatening hemorrhage.
May result from penetrating or blunt trauma
Causes massive hemorrhage

Signs of an open fracture include:

Blood in the vaginal or rectal regions
Pelvis
Signs of a stable injury
include:
Pain in the pelvis
Difficulty bearing weight
Signs of profound injury
include:
Shock
Gross instability
Diffuse pain
Possible bruising or lacerations
Possible hematuria
Pelvis
Assess mental status and ABCs.
Assess the pelvis for bleeding, lacerations, bruising, and instability.
A search for entry and exit wounds should not delay transport.
Pelvis
Treatment should include: The goal of management is to:
Monitoring ABCs Reduce bleeding.
Spinal stabilization Decrease instability.
IV access May include pelvic binder
Pelvis
To apply a pelvic binder:
Place binder over the trochanters
and below the ribs.
Connect sides.
Apply pressure from either side.
Perform definitive tightening.

EMS facility courtesy of St. Charles County Ambulance District, Missouri, Ray
Kemp/911 Imaging
Femoral Shaft
Fractures occur following high-energy impacts.
Signs and symptoms may include:
Angulation
Limb shortening
Thigh edema
Crepitus
Neurovascular damage
Femoral Shaft
Treatment includes:
Monitoring for shock
Full spinal immobilization
Establishing vascular access
Use of a traction splint or PASG
Administration of pain medication
Knee
Fractures result from direct blows, axial load of the leg, or contractions of quadriceps.
Signs and symptoms include:
Significant pain
Decreased ROM
Ecchymosis, swelling, deformity
Knee
Management depends on status of pulses
Good distal pulsesplint extremity in position found.
No pulseseek medical consultation.

Elevate the leg and apply cold packs.

Perform frequent neurovascular checks.
Tibia and Fibula
Fractures may result from direct trauma or rotational or compressive forces.
Signs and symptoms may include:
Significant deformity
Soft-tissue injury
Tibia and Fibula
Treatment:
Apply a rigid splint.
Administer pain medication.
In case of angulation, attempt to align the leg.
Elevate the extremity to heart level.
Apply cold packs.